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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372001648
Report Date: 12/22/2021
Date Signed: 12/22/2021 10:41:37 AM

Document Has Been Signed on 12/22/2021 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SILVERMAN PRESCHOOL OF TIFERETH ISRAEL SYNAGOGUEFACILITY NUMBER:
372001648
ADMINISTRATOR:AMY STANLEYFACILITY TYPE:
850
ADDRESS:6660 COWLES MOUNTAIN BOULEVARDTELEPHONE:
(619) 697-1948
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 89TOTAL ENROLLED CHILDREN: 74CENSUS: 36DATE:
12/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer LowTIME COMPLETED:
10:50 AM
NARRATIVE
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On 12/22/21 @ 9:30AM, Licensing Program Analyst (LPA) Nancy Diaz conducted an unannounced case management inspection. LPA toured all the classrooms with Acting Site Director Jennifer Low. Observed present today were 36 preschool children in the following classrooms:
Room #3 with 7 children and staff Larisa Borukhova & Kadija Osman.
Room #2 with 7 children and staff Madison Sigurdson, Emily Castillo & Brittany Fabing.
Room #8 with 5 children and staff Melina Huerta, Savannah Drover, Wisam Alimari & Katelyn Elleraas.
Room #10 with 5 children and staff Jessica Wheeler.
Room #11 with 4 children and staff Eliza Rodriguez & Bahar Rezaei.
Room #12 with 5 children and staff Even Sabri, Bianca Martinez & Sinia Fruge.
Room #14 with 3 children and staff Diana Korkis & Erin Vanderwyde.

Type A & B deficiencies were cited today. Civil penalty was also assessed.
Type A and B deficiencies were cited today. Civil penalties were also assessed.
Type A deficiency if not corrected will have a direct and immediate risk to the health, safety or personal rights of children in care.
Type B deficiency if not corrected poses a potential risk to the health, safety or personal rights of children in care.

An exit interview was conducted with Jennifer Low. Appeal rights were discussed a copy provided. Notice of site visit was observed posted. This notice shall remain posted for 30 days.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2021 10:41 AM - It Cannot Be Edited


Created By: Nancy Diaz On 12/22/2021 at 10:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SILVERMAN PRESCHOOL OF TIFERETH ISRAEL SYNAGOGUE
FACILITY NUMBER: 372001648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
CCR
101170(e)(1)

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CRIMINAL RECORD CLEARANCE. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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CORRECTED TODAY.
Mrs. Low submitted via fax today form LIC 9182, LIC 508 and a copy of photo ID.
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This requirement was not met as evidenced by: Based on file review and observation by LPA, staff Kadija Osman who was supervising in Room #3 did not have a fingerprint clearance associated to the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tashima Daniel
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2021 10:41 AM - It Cannot Be Edited


Created By: Nancy Diaz On 12/22/2021 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SILVERMAN PRESCHOOL OF TIFERETH ISRAEL SYNAGOGUE
FACILITY NUMBER: 372001648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2021
Section Cited
CCR
101212

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REPORTING REQUIREMENTS.
Upon the occurrence, during the operation... any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report...Shall be submitted to the Department within seven days following the occurrence of such event.
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Mrs. Low stated that she will complete form LIC 624 and fax a copy to the department (619) 767-2203 no later than end of business day today. Mrs. Low was reminded that all incidents requiring a medical attention must be reported to the department via telephone within 24 hours and a written report with 7 days of occurrence.
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This requirement was not met as evidenced by LPA's interview with staff. On 12/16/21 a child sustained an injury that required a dental visit. Child sustained injury to the gum area and superficial cut on the cheek. Director failed to report this incident to the department.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tashima Daniel
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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